Newport News, Virginia
Overview
Works under the supervision of the department leadership and is responsible for working in collaboration with the healthcare team to coordinate the care and service to patients across the continuum of care, promotes effective utilization and monitoring of healthcare resources and assumes a leadership role with the interdisciplinary team to achieve optimal quality, clinical and resource outcomes. Works to provide a comprehensive range of services or clinical care associated with and in accordance with standards of excellence established by Riverside Health system and facility goals and strategic plans. Utilizes national hospital based ACMA Scope of Services and Standards of Practice as foundation of Care Management.
What you will do
- Lead discharge planning from admission through post-discharge follow-up. Conduct comprehensive assessments of patients’ clinical, psychosocial, and discharge planning needs. Develop, implement, and update individualized and cost-effective discharge plans. Utilizes sequencing of interventions for safe, timely, efficient, effective, equitable, and patient-centered transitional planning. Coordinate safe and timely transitions to appropriate levels of care including but not limited to home, skilled nursing facility, acute rehab, and behavioral health.
- Collaborate with the interdisciplinary team, patient, their family/support system, payers, and community resources to ensure a smooth transition of care. Act as a liaison between the clinical team, patient and family, and any external agencies in the development of safe discharge plans. Participate in daily rounds, case conference, family meetings, weekly outlier case reviews, and multidisciplinary team meetings, communicating discharge updates clearly and proactively to all stakeholders.
- Ensure compliance with federal and state discharge planning regulations, in accordance with CMS’ Conditions of Participation. Monitor length of stay and identify/resolve barriers to timely discharge. Promote transparency and open communication by maintaining accurate, timely, and compliant documentation in the medical record. Maintain current knowledge of care management best practices and regulatory changes and understand Medicare/Medicaid, managed care, and other payer requirements. Delivers all notices (i.e. Important Message from Medicare, Medicare Outpatient Observation Notice) appropriately and according to CMS regulatory guidelines.
- Promote patient-centered care and shared decision-making in the development of appropriate discharge plans. Educate patients and families on treatment plans, discharge options, and available resources. Places referrals to complex case management as needed.
- Participate in quality improvement initiatives related to readmissions, throughput, and patient outcomes. Identify and document internal and external avoidable days. Act as a resource to fellow non-clinical care coordinators and assist with appropriate discharge planning as necessary.
Qualifications
Education
- Program Graduate, Nursing - Diploma Program (Required) or
- Associates Degree, Nursing (Required) or
- Bachelors Degree, Nursing (Preferred)
Experience
- 3-4 years Clinical experience required (may include LPN experience) (Required)
- 1 year Case management experience (Preferred)
Licenses and Certifications
- Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire(Required)
- Accredited Case Manager (ACM) - American Case Management Association (ACMA)/CCM Upon Hire (Preferred)
To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.